Provider Demographics
NPI:1598721953
Name:VANNERSON, JULIE A (MD)
Entity Type:Individual
Prefix:DR
First Name:JULIE
Middle Name:A
Last Name:VANNERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:8910 PURDUE RD
Mailing Address - Street 2:STE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-3161
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1002 WISHARD BLVD
Practice Address - Street 2:PCC 4TH FLOOR
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2872
Practice Address - Country:US
Practice Address - Phone:317-692-2323
Practice Address - Fax:317-656-3967
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01064152A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200870800Medicaid
3870296Medicare ID - Type Unspecified
IN200870800Medicaid
IN715530BPPPMedicare PIN